CHAPTER 13

Will you do the operation, Doctor?

Heart surgery is not purely about what happens in the operating theatre and the intensive care unit. In elective operations nothing would happen without, first, the cardiologist having referred the patient to a surgeon, and, second, the surgeon having seen the patient in a clinic to ascertain whether an operation is a good idea and whether the patient actually wants it.

Having decided that yes, it might be in the interests of a particular patient to be cut open and have his or her heart fixed, the next step involves explaining the benefits and risks. The benefits are relatively easy: relief of angina; relief of breathlessness; protection from future heart attacks and an early death; and so on. The risks are a little bit harder and need some thought. Most surgeons use EuroSCORE to predict the risk of death — a quick online calculation in which a few questions are answered about the patient, the heart and the planned operation, and the calculator instantly produces a percentage figure for the risk of death. Feel free to try it if you are curious about your own risk of heart surgery at www.euroscore.org. Most surgeons quote the risk directly from the EuroSCORE calculator, but wiser ones make an adjustment for their own figures, tweaking it up or down, depending on how they themselves have been performing in recent years. We then quote the likely risk of stroke, as it is yet another important factor in the patient’s decision, as well as common risks associated with any operation, such as bleeding, infection and so forth. Finally, we quote any risks which may be specifically attached to the particular planned operation. Beyond that, it is truly difficult to know what else to disclose. We could, of course, go so far as quoting every possible risk under the sun, including those which are so infinitesimally small as to be ridiculously improbable (such as being run over by a delivery truck in the hospital car park, falling out of hospital windows, and being set on fire by the surgeon), but my feeling is that, if we go this far, the patient will run for the hills. By and large, cardiac surgeons are very honest with their patients and some, like me, brutally so. I do not mince my words when I mention that death and stroke are a real risk, using words such as ‘You have to realise that this operation might kill you: there is a 1 in 100 chance that you will leave the hospital dead or seriously damaged.’ Of course, in many of my patients, not having the operation carries an even bigger risk, so I tell the patients about that too.

At the end of the consultation I usually ask the patient and the family if they have any questions left unanswered. The most commonly asked question is ‘How long will I have to wait?’ and, in the dire state of the NHS now, that is a particularly difficult one to answer. As I said in the previous chapter, in the bad old days of the early 1990s waiting times of well over a year were quite common, and the death rate from waiting was substantial. Then the Blair-Brown government took over and, for the first time in its history, the NHS was — almost — properly funded. Waiting lists and waiting times shrank right across the country and in some places and specialties, disappeared altogether. Now, with austerity and penny-pinching in all public services, the bad old days are coming back. Some of my patients again have to wait up to a year and, once more, we are beginning to see patients suffer from these excessively long waits. I am now unable to answer this question in any satisfactory manner, and have to resort to an utter cop-out: ‘We aim to treat all patients within about three months, but I’ll be honest with you and say that we don’t always achieve that.’

The second most commonly asked question is ‘Will you do the operation, Doctor?’ and that, too, is a difficult one to answer. What actually happens is that the senior surgeon hardly ever does the operation in its entirety. In most heart operations, opening the chest, joining the patient to the heart-lung machine and closing the chest at the end of the operation are done by experienced trainees who have done this hundreds of times, and they do all of that on their own. The senior surgeon is usually present for the essence of the operation, the bit in which the heart itself is fixed. That presence could be either as primary operating surgeon, doing the cutting and stitching, or as a supervisor and first assistant to the trainee, who actually does the cutting and stitching. In my practice, about half of the operations done in my name are actually done by a trainee with my direct help and supervision. Does that matter?

Fortunately, it does not. The old perception of the gifted and skilled surgeon who has abilities others do not have may be an attractive and glamorous one, but it is no longer true. Firstly, heart operations are never done by one individual. In a typical coronary artery bypass graft operation (or CABG) there is a team of around 10 people in the operating theatre: a senior anaesthetist and a trainee put the patient to sleep, insert the breathing tubes and monitoring lines; and they administer any drugs needed during the procedure. They are supported in this by an Operating Department Practitioner. The heart-lung machine is run by two perfusionists.

At the leg end of the patient, a Surgical Care Practitioner (or SCP) takes a vein from the leg to use as a coronary bypass. SCPs are not even medically qualified as doctors: they hail from all parts of health care, but are specifically trained in the technical and surgical skills necessary to perform this task. When I started my own training in heart surgery, this was the job that was delegated to the most junior surgeons on the team and we often botched it until we had acquired some experience. Nowadays it is done by experienced and skilled SCPs with a portfolio of hundreds of cases behind them; and, if a junior surgical trainee needs to acquire experience in this, it is the SCP who provides that training.

At the chest end, there is usually a consultant surgeon and a registrar, who is a senior trainee, doing the bits on the heart. In a CABG operation the registrar, within a year or two of starting specialist training, will have acquired the ability to open the chest, take down the mammary artery and insert the pipes in preparation for the heart-lung machine, and will be able to do so unaided. No matter how experienced and confident the registrars are, they are all taught that the first ‘surgical instrument’ they must master is the telephone: if anything unexpected is found or actually happens when the senior surgeon is not physically present in the operating theatre, they must use the telephone to call for help and support, and we are never more than a minute or two away.

When the preparations are complete and the time has come for the nitty-gritty part of the procedure, how much of the actual cutting and stitching of the bypasses themselves is then done by the registrar depends on three factors: the registrar’s level of ability, the consultant’s willingness to train, and the level of technical difficulty posed by the coronary arteries themselves. In almost all of my CABG operations, the trainee will do at least some cutting and stitching, and, if conditions permit, the trainee will do most of the technical work. The one thing that I never delegate to a trainee is the decision-making: what to bypass, where to bypass and how to do it. There, I tend to cling to total control over what happens in my operating theatre until I feel that the trainee is now not only as good as (or often technically better than) I am, but also that he or she will make decisions that are as good as mine. Only then, towards the very end of their training years, do I allow them to ‘fly solo’. By now they will be ready for a consultant post and actively seeking such an appointment to move to and start their career ‘properly’. Until they reach this point, they may well be doing some or even all of the cutting and stitching, although, in reality, I am still doing the operation, but sometimes using their hands.

There is no choice but to train. If we do not, the specialty will die out, and, from a purely selfish viewpoint, when I retire and need a CABG, there may be nobody around to do it. It is, however, important that the training of junior surgeons should not damage patients. To that end, we audited all CABG operations in which a junior was the primary operator as in the above model, with the senior assisting, and compared them with those in which a senior surgeon was the primary operator. It was a major study of over 2,700 patients. We found absolutely no difference in outcomes. The system that we have at Papworth therefore works and is safe.

So: will you do the operation, Doctor?

My stock answer is the following: ‘My team and I will do the operation. It takes many people to do it, but I promise you that I will be part of the team and I will be there.’